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Page 2 of 15 Crowe et al. Plast Aesthet Res 2019;6:4 I http://dx.doi.org/10.20517/2347-9264.2018.70

INTRODUCTION
Lower extremity injuries resulting in dysfunction and deformities can be due to a variety of conditions
including congenital abnormalities, trauma, burns, vascular disease, and neuropathic disorders (including
diabetes, leprosy, nutritional deficiency, axonal degeneration and demyelinating processes). Regardless of
etiology, surgical reconstruction or amputation is often considered to restore function in the extremity
[1]
when more conservative treatments are unsuccessful . The decision about which option is optimal for
an individual patient can be challenging. Substantial prior research has compared reconstruction with
[4,5]
[2,3]
[6,7]
amputation in terms of function , quality of life , and cost-effectiveness . One of the most important
considerations in determining optimal surgical treatment is the prosthetic and orthotic options to restore
function after surgery. Recently, advances in prostheses and orthoses have provided patients with a wider
range of options to consider when deciding limb reconstruction vs. amputation.
Prosthetic restoration following lower extremity amputation has several goals. The first, and arguably the
most important, is to reestablish functional mobility and static positioning of the limb. Ambulation using
[8]
a prosthesis requires increased energy expenditure as the amputation level moves proximally . Therefore,
a lower limb prosthesis should be designed and fit to minimize this increase in energy expenditure [9,10] .
Secondly, well-fitting prostheses also serve to prevent breakdown of remaining soft tissue by redistributing
[11]
compressive force during weight bearing and minimize the amount of shearing force on the skin . Lastly,
the use of conventional footwear and clothing should be considered when prescribing an adaptive prosthesis,
though this may not always be of patient concern. The psychological impact of amputation and its effect on
[12]
social functioning and identity should not be underestimated .
Reconstruction may be pursued when the patient has a reasonable chance at weight bearing and functional
ambulation. The decision to reconstruct vs. amputate also depends on the neurologic and vascular status
of the limb, presence of fracture, risk for ongoing wounds or infection as well as the functional goals of the
patient. At times, amputation of the limb may provide a better chance at more fully restoring function in
the limb than does limb restoration, and vice versa. The number of surgeries and overall time spent actively
[13]
rehabilitating is greater for limb salvage with reconstruction as compared to amputation . Despite this
initial healthcare utilization, the projected lifetime cost of lower extremity reconstruction is considerably
[6]
lower than amputation . The impact of multiple surgeries and subsequent recovery on the overall health of a
person should also be considered when deciding between reconstruction vs. amputation.

Unlike amputation, which can be divided into categories by level, the reconstruction of the lower limb
does not necessarily follow a discrete algorithm in terms of post-reconstruction adaptive devices. Instead,
individual defects - their etiology, location, size and depth - must be considered alongside patient factors to
determine the need for specific postoperative orthosis. The primary goals of any adaptive device are similarly
to improve function, prevent recurrence or ulceration of the defect, and allow for use of conventional
footwear and/or clothing.

In this article, we present the surgical considerations of various types of lower extremity amputation and
reconstruction, and provide a framework for the role of postoperative adaptive devices including prostheses
and orthoses.

LOWER EXTREMITY AMPUTATION
When amputation of the limb is deemed medically appropriate, selection of the correct level is of critical
importance for healing potential and for optimal function. The location of amputation and resulting residual
length and limb shape help determine function, energy expenditure necessary for ambulation, and prosthetic
options for the amputated limb. Generally speaking, a more distal amputation is more functional as it